C e n t r a l A A U R e g i o n a l V I K a r a t e C h a m p i o n s h i p s. April 24-26, 2015 Grayslake, Illinois

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1 C e n t r a l A A U R e g i o n a l V I K a r a t e C h a m p i o n s h i p s April 24-26, 2015 Grayslake, Illinois DATE: April 24- April 26, 2015 TIME: LOCATION: HOST: Friday clinics 6 PM - 8 PM 4-25 & tournament - 9 AM - 4 PM College of Lake County J.B. Mirza, Traditional Karate-Do Organization ENTRY DEADLINE: April 20, 2015 ENTRY FEE: $70 AGE: 5 and up This event is sanctioned by the Amateur Athletic Union of the U. S., Inc. All participants must have a current AAU membership. AAU membership may not be included as part of the entry fee to the event. AAU membership must be obtained before the competition begins except where the event operator has a laptop available with an internet connect. Participants are encouraged to visit the AAU web site to obtain their membership. FOR MORE INFORMATION: J.B. Mirza ph fax

2 AAU Karate 237 East Prospect Avenue Mount Prospect, IL AAU KARATE REGION VI CHAMPIONSHIPS April 25-26, 2015 COLLEGE OF LAKE COUNTY - GRAYSLAKE, ILLINOIS Referee & Coach Clinic April 24, 2015 NATIONAL KARATE COMMITTEE Chairman, J.B. Mirza Phone: Sanctioned by: Amateur Athletic Union of the United States

3 AAU KARATE REGION VI CHAMPIONSHIPS April 25-26, 2015 PLEASE PRINT! Last Name First Name (area code) Phone # Address City State Zip BIRTHDATE: / / AGE: SEX: Male Female WEIGHT: lbs (Mo./day/yr.) (As of ) If age is challenged, please be able to produce proof of age, such as a birth certificate, passport, etc. Dojo Name Sensei s Name 2015 AAU NUMBER* If not a member, see below Karate Experience I WILL COMPETE IN THE FOLLOWING CATEGORIES Check one below: Beginner Less than 1 year Novice More than 1 yr., less than 2 yr. Kobudo - Weapons Kata - 5 yr. thru 17 yr. and 35 & up Open Flag Kata - 16 yr. or older advanced only Intermediate Mandatory Kata - 16 yr. or older advanced only 2 yr., less than 4 yr. (3 rounds - Shitei/Sentei/Tokui) Advanced Kumite (Sanbon) 4 yr. or more Seniors (35 + years) only: I am a senior/master and wish to compete in adult group (ages 18-34). (Check this box ONLY if you wish to compete in this group) Medical Information: Check one below: I have NO medical problems I have medical problems, but I am able to compete. Describe medical problem(s), or attach Doctor s note WAIVER I hereby for myself, my executor(s), my heirs, forever and always agree to save and hold harmless the Amateur Athletic Union of the United States and all of its officers, referees, judges, volunteers, workers, members, tournament director, tournament promoter, tournament employees, the facility owners, their respective officers, agents, successors, and anyone else involved in the conduct of this karate tournament for any liability or injury I may sustain by way of traveling to and from, participating in, or other direct or indirect involvement in the AAU/USA Karate Tournament that I have entered. In addition, I hereby for now and forever, accept any and all responsibilities for any actions in conjunction with the AAU/USA Karate Tournament and the traveling to or from or participating in said event. Finally, I agree to allow, without compensation, the use of any photographs, films, or videotape of myself. SIGNATURE: (Parent or Guardian if under 18 years of age) TOURNAMENT FEE: $70.00 / COACH FEE $25.00 *AAU Membership (AB card): $ 16 youth (17 yrs & under), $29 adult (18 & up), $18 coach membership (all ages) If not a current 2015 AAU member, please apply for membership: www aausports.org Applications must be received by April 20, 2015 Those received between April 21st & April 24 th will be an additional $35.00 No applications will be accepted after April 24, Enclose certified checks or money orders (no personal checks) payable to: TKO Mail to: AAU Karate East Prospect Ave, Mt. Prospect, Illinois 60056

4 AAU KARATE REGION VI CHAMPIONSHIPS EVENT INFORMATION RULES & REGULATIONS Tournament Mandatory Equipment: Director: Mr. J. B. Mirza White Naugahyde/leather fist guards, (AAU approved) Host: Traditional Karate-Do Organization White Foam Headgear with face shield (Juniors) 237 East Prospect Avenue Groin Cup Protector (Males) Mount Prospect, IL Mouth guard Date: April 25-26, 2015 Location: College of Lake County Optional Equipment: W Washington St., Grayslake, Il White Cloth Shin Pads (Adult) Start Times: Tournament Begins - 9 am White Cloth Shin/Instep Pads (Youth) Age: 5 thru Adult Individual Competition White Foam Open Face Headgear (Adult) Competitions: Kata (Forms) Kobudo (Weapons) Kumite (Fighting) Rules: AAU/USA - WKC Sanctioned by: Amateur Athletic Union of the U.S. Fees: Spectators: $6.00 / 5 years of age & up Competitors: Please note: Divisions may be combined by age / experience level Qualifier: 2015 AAU National Karate Championships (top 16 each division) 2015 Junior Olympic Championships (top 4, age 7-20 Intermediate & Advanced divisions) DRESS CODE THE OFFICIAL AAU KARATE PATCH MUST BE WORN FOR THIS COMPETITION (SEWN ON GI) BEGINNER MUST WEAR WHITE BELT NOVICE MUST WEAR GREEN BELT INTERMEDIATE MUST WEAR BROWN BELT ADVANCED MUST WEAR BLACK BELT Traditional Solid White Gi (no piping or stripes) No Rolled Sleeves or Cuffs Pants must be 3/4 Length (between ankle and knee) Sleeves Must Be 3/4 Length (between wrist and elbow) Females Must Wear Plain White T-shirt or White Sport Bra Under Top No Headbands or Jewelry CLINICS: FRIDAY, APRIL 24, :00 PM - College Of Lake County REFEREES & COACHES: Attendance is required for participation as a referee or coach at the tournament. REFEREE APPLICATION NAME AREA CODE & PHONE NUMBER 2015 AAU # ADDRESS CITY STATE ZIP AAU LICENSE RATING STYLE CLUB Referee Clinic: mandatory to referee / no fee COACH APPLICATION NAME AREA CODE & PHONE NUMBER 2015 AAU # ADDRESS CITY STATE ZIP STYLE CLUB Coach Clinic: mandatory to coach / $25 fee ALL REFEREES & COACHES: Please Submit Double Gold Certificate & AAU non-athlete membership with application

5 Saturday April 25, 2015 AAU KARATE REGION VI CHAMPIONSHIPS TOURNAMENT SCHEDULE 08:30 AM All Referees & Volunteers (assigned to rings) 09:00 AM Team Kata 9-12 year old male & female 09:00 AM Kobudo Advanced Adult 09:30 AM Open Flag Kata Advanced male & female-(16 & up) 10:00 AM Kobudo & Kata All 5-8 year old male & female 10:30 AM Kobudo & Kata All 9-10 year old male & female 11:00 AM Kobudo & Kata All year old male & female 12:00 PM Kobudo & Kata Senior & Adult: Beginner, Novice & Intermediate male & female 1:00 PM Kumite All 5-8 year old male & female 1:30 PM Kumite All 9-10 year old male & female 2:00 PM Kumite All year old male & female 2:30 PM Kumite Senior & Adult: Beginner, Novice & Intermediate male & female 3:00 PM Team Kumite 9-12 year old male & female Sunday April 26, :30 AM All Referees & Volunteers (assigned to rings) 08:45 AM Team Kata year old male & female 09:00 AM Mandatory Kata 09:30 AM Kobudo & Kata 10:30 AM Kobudo & Kata 11:00 AM Kobudo & Kata 11:30 AM Team Kata (16 years & older advanced - male & female - 3 ROUNDS) All year old male & female All year old male & female Advanced Senior (male & female) for Kobudo & Kata year old & 18+ male & female 12:00 PM Kumite 12:30 PM Kumite 01:30 PM Kumite 02:30 PM Team Kumite All year old male & female All Senior - male & female / All year old male & female Advanced Adult - male & female / / 18+ male & female

6 AMATEUR ATHLETIC UNION 2015 Region VI Championships TEAM APPLICATION TEAM NAME: CITY: STATE: WE WILL PARTICIPATE AS A: Junior Team (Ages 9-12) Youth Team (Ages 13-15) Teen Team (Ages 16-17) Adult Team (Ages 18+) THIS TEAM CONSISTS OF: All Male Members All Female Members Combined * THIS TEAM WILL COMPETE IN THE FOLLOWING EVENTS: Kata Kumite (Sanbon) PLEASE NOTE: 1. Team participation level is determined by the age of the OLDEST Team Member (kata / kobudo) 2. All members of a kumite team Must be the same sex and in the same age category 3. Team Members MAY NOT compete in multiple levels (i.e. Teen and Adult) 4. * Under 18 may combine sexes in Teams for Kata ONLY!! Fees Owed: $30 One Event $60 Two Events $ Total Fees Paid NAME 2015 AAU # AGE Adult & Minor AAU Waiver and Release of Liability In consideration of being permitted to participate in any way in any Amateur Athletic Union of the U.S. Inc. ( AAU ) activity ("Activity") I, for myself, my personal representatives, assigns, heirs, and next of kin, the undersigned: 1. Acknowledge, agree, and represent that I understand the nature of the Activity and that I am qualified, in good health, and in proper physical condition to participate in such Activity. I further agree and warrant that if at any time I believe conditions to be unsafe, I will immediately discontinue further participation in the Activity. 2. Fully understand that: (a) athletic activities involve risks and dangers of serious bodily injury, including permanent disability, paralysis, and death (risks); (b) these risks and dangers may be caused by my own actions or inactions, the actions or inactions of others participating in the activity, the condition in which the activity takes place or the negligence of the "releasees" named below; (c) there may be other risks and social and economic losses either not known to me or not readily foreseeable at this time; and I fully accept and assume all such risks and all responsibility for losses, costs, and damages I incur as a result of my participation or that of the minor in the activity. CONTINUED ON BACK MUST BE COMPLETELY FILLED OUT AND SIGNED ON THE BACK BY ALL TEAM MEMBERS, PARENTS/GUARDIANS.

7 3. Hereby release, discharge, and covenant not to sue the Amateur Athletic Union of the United States (AAU), related affiliated and subsidiary companies, as well as the officers, directors, agents, employees and signs of each, and the AAU or WKO's association, clubs, coaches, officials, administrators, members, volunteers, participants, sponsors, advertisers, and if applicable, owners and lessors of premises on which the Activity takes place, and any other party indemnified and held harmless by the AAU (each considered one of the "Releasees" herein), from all liability, claims, demands, losses, or damages on my account caused or alleged to be caused in whole or in part by the negligence of the "releasees" or otherwise, including negligent rescue operations, negligent security, travel, and recreational operations and activities; and I further agree that if, despite this release and waiver of liability, assumption of risk, and indemnity agreement I, or anyone on my behalf, makes a claim against any of the releases, I will indemnify, save, and hold harmless each of the releasees from any litigation expenses, attorney fees, loss, liability, damage, or cost which any may incur as the result of such claim. 4. By my signature below I confirm that I am in sound health and there is no reason why I cannot participate in this championship and/or event. 5. No refunds will be given. All entries are final. I consent that any pictures taken of me in connection with this Tournament can be used for publicity or promotion, now or in the future, and I waive compensation in regard thereto. I fully understand that any medical treatment will be of a first aid treatment type only. All participation in any event or class in this tournament is by permission only. The Director or his authorized agent (s) reserve the right to refuses entry to any person, school, team or club. Please note: All Athletes, Coaches and Referees must be registered 2015 AAU members. All athletes must have qualified at a Regional or other typequalifying event. 6. All athletes, coaches, and referees must exhibit behavior and manners consistent with the code of ethics and good sportsmanship. Any acts or statements which are disruptive to the operation of the tournament or any division, or which are insulting, offensive or otherwise inappropriate may result in disqualification from the tournament. 7. All competitors will be required to appear for competition at the posted times. Any person who fails to appear when the division is called, or who fails to appear when their name is called in the division, may be disqualified. 8. All competitors must wear a clean, white karate Gi. No style patches, names, slogans of any kind are permitted on the uniform jacket or pants, except for the manufacturers labels. An Official AAU patch must be sewn on the left breast area of the Gi jacket 9. Any person electing to compete in any of the Senior divisions for ages 35 and older may not compete in any regular Adult divisions. 10. ALL ENTRIES ARE FINAL UPON REGISTRATION. IT IS THE RESPONSIBILITY OF THE COMPETITIOR TO BE SURE THAT THEY ARE ENTERED IN THE APPROPRIATE DIVISIONS; NO CHANGES OF DIVISIONS WILL BE MADE AFTER COMPETITOR CHECK-IN. ATHLETE S COMPETITION AGE IS AS OF JULY 1, I have read this agreement, front and back, (see back of application) fully understand its terms, understand that I have given up substantial rights by signing it and have signed it freely and without any inducement or assurance of any nature and intend it to be a complete and unconditional release of all liability to the greatest extent allowed by law and agree that if any portion of this agreement is held to be invalid the balance, notwithstanding, shall continue in full force and effect. Athlete s Signature (1)/Date Athlete s Signature (2) /Date Athlete s Signature (3)/Date MINOR RELEASE And I, the minor s parent and\or legal guardian, understand the nature of athletic activities and the minor s experience and capabilities and believe the minor to be qualified, in good health, and in proper physical condition to participate in such activity. I hereby release, discharge, covenant not to sue, and agree to indemnify and save and hold harmless each of the releasee s from all liability, claims, demands, losses, or damages on the minor s account caused or alleged to be caused in whole or in part by the negligence of the releasers or otherwise, including negligent rescue operations and further agree that I, despite this release, I, the minor, or anyone on the minor s behalf makes a claim against any of the releasers named above, I will indemnify, save, and hold harmless each of the releasers from any litigation expenses, attorney fees, loss liability, damage, or cost any may incur as the result of any such claim. Athlete s Signature (1) Signature of Parent/Guardian Date Athlete s Signature (2) Signature of Parent/Guardian Date Athlete s Signature (3) Signature of Parent/Guardian Date Please read entire form before signing. All information is required. Return this form by April 20, 2015 to AAU/USA Karate, 237 East Prospect Ave., Mount Prospect, IL Only money order or certified check made payable to TKO accepted.